Endometriosis
Imaging vs laparoscopy, pain and infertility management
Last updated: October 2026 — Sources: Cochrane / EAU / ESHRE / WHO / CDC
Key takeaways
ESHRE 2022 flips practice: laparoscopy no longer gold standard — imaging (US/MRI) first, then lap only if negative/failed empiric. Pain: NSAIDs+COC/progestin first, GnRH antagonists second, excision not ablation.
109 recs: no blood biomarker for dx; imaging first.
Laparoscopy improves short-term pain but live birth no clear diff — Cochrane Bafort 2020 low.
No hormones before surgery; 18–24 mo after to prevent dysmenorrhoea recurrence.
IUI+stimulation better than expectant in rASRM I/II; EFI post-op for fertility prognosis.
When to evaluate?
- Cyclic pelvic pain/dyspareunia/infertility — expert US first.
- Endometrioma/nodules — MRI if US inconclusive.
- Desiring pregnancy — EFI after lap to guide IUI vs IVF.
What not to do?
- Don't order CA-125 routinely for dx.
- Don't ablate instead of excise — guideline prefers excision.
- No pre-op hormones hoping to ease surgery.
Healthcare-professional notice
This hub is independent of NPF products and does not promote them. It is informational only and does not replace individual clinical judgment. Surrogate outcomes (SDF, motility, HOMA, IIEF) are never converted into pregnancy/cure promises, and GRADE certainty is quoted as published.
Binding rule: surrogate outcomes are never converted into patient outcomes. Every certainty grade and limitation is quoted as published.
Deep dive
New diagnosis
Laparoscopy with biopsy no longer mandatory — positive imaging suffices to start.
Negative imaging doesn't rule out superficial/peritoneal — selective lap.
Pain & infertility
Short NSAIDs + continuous COC/progestin — GnRH antagonists if first-line fails.
Surgery helps pain but decision by severity/pregnancy wish — Cochrane low.
Evidence in this domain
Each study broken into five questions: why it was run, who was studied, how it was done, the finding, and why it came out that way — then the clinical takeaway and limits, as published.
FAQ
Does surgery improve natural pregnancy?
In mild/moderate IUI+stimulation > expectant; in severe often IVF.
Notice: this reference is informational only and not a substitute for medical advice. Consult your doctor before making any treatment decision.